Disarticulation resections of the mandible: a prospective review of 16 cases.

PURPOSE: This article provides a review of the disarticulation resection of the mandible for various benign and malignant tumors and non-neoplastic processes. In so doing, the author proposes a classification to describe extension of pathology into the condylar region, thereby requiring its sacrifice. Recommendations are also proposed for preservation versus sacrifice of the meniscus when performing a disarticulation resection of the mandible. Finally, complications are evaluated in this type of mandibular resection. PATIENTS AND METHODS: This review is based on the author's accumulated clinical data obtained from performing disarticulation resections on 16 patients who presented with 10 different pathologic diagnoses. Disarticulation resections are performed for 3 different patterns of extension of pathologic processes into the condylar region, designated as type I, type II, and type III by the author. These designations reflect the radiographic involvement of the condyle or subcondylar region of the mandible by the pathologic entity. The designations of type II and type III extensions are diagnosis dependent, whereas type I extension is independent of diagnosis. RESULTS: Five patients in this series presented with type I condylar extension, 2 patients presented with type II condylar extension, and 9 patients presented with type III condylar extension. The meniscus required sacrifice in 3 of the 16 patients. Complications occurred in 3 of 16 patients and included 1 dislocation of the plate into the middle cranial fossa, 1 dislocation of the plate inferiorly and posteriorly to the mastoid process, and 1 cutaneous exposure of the plate. CONCLUSIONS: Disarticulation resections are rarely required variants of segmental resection of the mandible, and they are required by a variety of pathologic processes of the jaws and contiguous structures. The placement of a reconstruction bone plate with an affixed condylar prosthesis is well tolerated by patients and is associated with few complications. These reconstruction bone plates favorably support facial form, symmetry, and occlusion such that many patients delay their definitive bony reconstruction. Because these condyles are temporary prostheses, the surgeon should consider their removal with bony reconstruction of the disarticulation defect as soon as possible after the ablative surgery.     

Rapidly enhancing hepatic hemangiomas at MRI: Distinction from malignancies with T2-weighted images

The purpose of this study is to describe a subset of atypical hepatic hemangiomas that enhance rapidly and diffusely and to determine whether heavily T2-weighted images could distinguish between atypically enhancing liver hemangiomas and hypervascular malignancies. A retrospective search of MR records identified seven patients with liver hemangiomas that demonstrated diffuse early enhancement and 23 patients with biopsy-proven malignant liver lesions that were hypervascular on dynamic gadolinium-enhanced MR images. Quantitative analysis of signal intensity measurements was performed on the T2-weighted images, heavily T2-weighted (TE < 140), and dynamic gadolinium-enhanced images. Blinded reader comparison of the T2-weighted images and gadolinium-enhanced images was performed. Hypervascular hemangiomas enhanced to a greater degree than hypervascular malignant liver lesions on the early phase gadolinium-enhanced images. Perilesional parenchymal enhancement was demonstrated in five cases of rapidly enhancing hemangiomas. Signal intensity and contrast-to-noise ratios on the heavily T2-weighted images of the hemangiomas were significantly greater than that of the hypervascular malignant lesions (P < .05). Hemangiomas were differentiated from the hypervascular malignant liver lesions with high accuracy (97–100%) by three blinded readers based on the T2-weighted images. A subset of hemangiomas have atypical rapid diffuse enhancement on dynamic gadolinium-enhanced images. These atypical hemangiomas can be distinguished from hypervascular malignant liver lesions on T2-weighted MR images.     

Individualized versus standardized therapy: A comparative evaluation with obsessive-compulsive patients

The aim of this study was to investigate whether individualized tailor-made behavioural treatment based upon a problem analysis of each case was more effective than a standardized behavioural treatment protocol. Twenty-two obsessive-compulsive patients were randomly assigned to two treatment conditions: (1) tailor-made cognitive behavioural therapy and (2) standardized exposure in vivo therapy. Treatment in both conditions led to significant improvements on obsessive-compulsive targets and on the Maudsley Obsessional-Compulsive Inventory. Improvement generalized to general levels of psychopathology, depressed mood and social anxiety. Contrary to expectations the individualized treatment was not more effective than the standardized exposure therapy.     

Development of quality of care indicators for Parkinson's disease.

Parkinson's disease (PD) is a major cause of disability. To date, there have been no large-scale efforts to measure the quality of PD care because of a lack of quality indicators for conducting an explicit review of PD care processes. We present a set of quality indicators for PD care. Based on a structured review of the medical literature, 79 potential indicators were drafted. Through a two-round modified Delphi process, an expert panel of seven movement disorders specialists rated each indicator on criteria of validity, feasibility, impact on outcomes, room for improvement, and overall utility. Seventy-one quality indicators met validity and feasibility thresholds. Applying thresholds for impact on outcomes, room for improvement, and overall utility, a subset of 29 indicators was identified, spanning dopaminergic therapy, assessment of functional status, assessment and treatment of depression, coordination of care, and medication use. Multivariable analysis showed that overall utility ratings were driven by validity and impact on outcomes (P < 0.01). An expert panel can reach consensus on a set of highly rated quality indicators for PD care, which can be used to assess quality of PD care and guide the design of quality improvement projects.     

Premature failure of small-sized Shelhigh No-React porcine pulmonic valve conduit model NR-4000.

OBJECTIVE: Given the limited availability of small-sized cryopreserved pulmonary homografts, we implanted a series of Shelhigh No-React porcine pulmonic valve conduits (SPVC). The aim of this study was to evaluate the short-term performance following implantation. METHODS: From February 2000 to September 2000, the SPVC was implanted 25 times in 24 patients in the right ventricular outflow tract (RVOT) to correct congenital anomalies. The anatomical malformations were TOF/PA in eight patients, TGA/VSD/PS in four, truncus arteriosus in four, IAA/VSD/AS or AA in four, l-TGA/VSD in two and other in two. Age at operation was 2.8+/-3.9 years (mean+/-SD), including 12 patients under 1 year. The median conduit size was 14mm (range, 10-18). RESULTS: At a mean follow-up of 23+/-5 months, two late deaths (8%) have occurred. Although they were not primarily conduit related, both showed severe conduit stenosis. Twenty-one conduits (84%) showed mild to severe conduit stenosis, regurgitation or both. Two patients underwent balloon dilatation for distal conduit stenosis. Twelve conduits (48%) in 11 patients were removed at a median of 12 months (range, 2-18 months) due to RVOT obstruction in 11 and free conduit insufficiency with pseudoaneurysm in one. The typical findings of the explanted conduits were prominent intimal peel formation at the distal anastomosis without calcification. The actuarial freedom from reintervention at 18 months was 48+/-10%. CONCLUSIONS: Our experience of the SPVC with the diameter of 14mm or less has revealed a high incidence of distal conduit stenosis due to intimal peel formation resulting in early conduit failure. These findings have led us to abandon its use when other options are available.